Fillable Form 1152 Designation of Beneficiary

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Form 1152 Designation of Beneficiary

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Designation of Beneficiary
Important:
Unpaid Compensation of Deceased Civilian Employee
Read all instructions before
filling in this form
A. Identification
Name
(Last, first, middle)
Date of birth
(mm, dd, yyyy)
Social Security Number
Department or agency in which presently employed
(or former department or agency)
:
Department or agency Bureau Division Location
(City, state and ZIP code)
I, the employee named above, canceling any and all previous Designations of Beneficiar y heretofore made by me, do now
designate the beneficiary or beneficiaries named below to receive any unpaid compensation due and payable after my death.
I understand that this Designation of Beneficiary relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no
way will affect the disposition of any benefit which may become pa yable under the Retirement or Group Life Insurance Acts
applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect
until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another
department or agency of the Government.
B. Information Concerning The Beneficiaries (See Examples of Designations):
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
Date of designation
(mm, dd, yyyy)
Your signature
Total = %
C. Witnesses (A witness is not eligible to receive payment as a beneficiary):
We, the undersigned, cer tify that this statement was signed in our presence.
Signature of witness Number and street City, state and ZIP code
Signature of witness Number and street City, state and ZIP code
Receiving agency certification
I have reviewed this designation and cer tify that the designated shares total 100% and that no witnesses are designated as beneficiaries.
Date received Signature Date
Type or print your return address to insure return
U.S. Office of Personnel Management All Previous editions
Standard Form 1152
Part 1 - Original
5 CFR 178 NSN 7540-00-634-4340 are not usable.
Revised September 2011
Print Form
Save Form
Clear Form
Important - The filing of this form will completely cancel any Designation of Beneficiary you may have previously filed. Be sure to name
in this form all persons you wish to designate as beneficiar ies of any unpaid compensation payable at your death.
Examples of Designations
1. HOW TO DESIGNATE ONE BENEFICIARY
Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate
as beneficiary, enter “My estate” in the beneficiary column.
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
Mary E. Brown 214 Central Avenue
Muncie, IN 47303
Domestic Partner 100%
2. HOW TO DESIGNATE MORE THAN ONE
Be sure that the shares to be paid to the several beneficiaries add up to 100 percent.
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
Alice M. Long 509 Canal Street
Red Bank, NJ 07701
Aunt 25%
Joseph P. Brady 360 Williams Street
Red Bank, NJ 07701
Nephew 25%
Catherine L. Rowe 792 Broadway
Whiting, IN 46394
Mother 50%
3. HOW TO DESIGNATE A CONTINGENT BENEFICIARY
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
John M. Parrish, if living 810 West 180th Street
New York, NY 10033
Father 100%
Otherwise to: Susan A. Parrish 810 West 180th Street
New York, NY 10033
Sister 100%
4. HOW TO CANCEL A DESIGNATION OF BENEFICIARY AND EFFECT PAYMENT UNDER ORDER OF PRECEDENCE (See back of duplicate)
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
Cancel prior designations
U.S. Office of Personnel Management
Standard Form 1152
(Reverse of Part 1)
5 CFR 178 Revised September 2011
Designation of Beneficiary
Important:
Unpaid Compensation of Deceased Civilian Employee
Read all instructions before
filling in this form
A. Identification
Name
(Last, first, middle)
Date of birth
(mm, dd, yyyy)
Social Security Number
Department or agency in which presently employed
(or former department or agency)
:
Department or agency Bureau Division Location
(City, state and ZIP code)
I, the employee named above, canceling any and all previous Designations of Beneficiary heretofore made by me, do now
designate the beneficiary or beneficiaries named below to receive any unpaid compensation due and payable after my death.
I understand that this Designation of Beneficiar y relates solely to money due as defined in 5 U.S.C. 5581, 5582, 5583, and in no
way will affect the disposition of any benefit which may become payable under the Retirement or Group Life Insurance Acts
applicable to my Government service. I further understand that this Designation of Beneficiary will remain in full force and effect
until (1) I expressly change or revoke it in writing, (2) I transfer to another agency, or (3) I am reemployed by the same or another
department or agency of the Government.
B. Information Concerning The Beneficiaries (See Examples of Designations):
First name, middle initial, and last
name of each beneficiary
Address (Including ZIP code) of
each beneficiary
Relationship Share to be paid to
each beneficiary
Date of designation
(mm, dd, yyyy)
Your signature
Total = %
C. Witnesses (A witness is not eligible to receive payment as a beneficiary):
We, the undersigned, cer tify that this statement was signed in our presence.
Signature of witness Number and street City, state and ZIP code
Signature of witness Number and street City, state and ZIP code
Receiving agency certification
I have reviewed this designation and certify that the designated shares total 100% and that no witnesses are designated as beneficiaries.
Date received Signature Date
Type or print your return address to insure return
U.S. Office of Personnel Management All previous editions are Standard Form 1152
Part 2 - Employee Copy
5 CFR 178 NSN 7540-00-634-4340 not usable. Revised September 2011
IMPORTANT NOTICE – ORDER OF PRECEDENCE
If there is no designated beneficiary alive at the time of your death, any unpaid compensation owed you (that becomes payable
after you die) will be paid to the first person or persons in the order listed below who are alive on the date that entitlement to
the payment occurs.
1. To your widow or widower.
2. If neither of the above, to your child or children in equal shares. The share of an y deceased child is distributed to the
descendants of that child.
3. If none of the above, to your parents in equal shares or the entire amount to the surviving parent.
4. If none of the above, to the duly appointed legal representative of your estate. If there is none, to the person or persons
entitled under the laws of the State or other domicile where you lived.
You do not need to designate a beneficiary unless you want to name some person or persons not listed above or you want
the payment to be made in a different order.
INSTRUCTIONS
1. The examples on the back of the first page of this form may be helpful to you in filling out this form.
2. Except for signatures, you should type or print all entries in ink (typing is preferred). You should use this form for any
designation of beneficiary or beneficiaries. The form must be signed and witnessed.
3. The form should be free of erasures or alterations to avoid a possible legal contest after your death.
4. You do not need to fill out a new form when y our name or address changes or when the name or address of your
beneficiary changes.
5. You must complete the form in duplicate and file it with your employing agency. To be valid, your agency must receive the
completed form prior to your death. The duplicate will be annotated and returned to you as evidence that the original was
received and filed with your agency. We suggest that you file the duplicate with your important papers.
6. You can cancel any prior Designation of Beneficiary form without naming a new beneficiary by completing a new form and
inserting “Cancel prior designations” in the space provided for the name of beneficiary. This will change the payment to
the order of payment described under “Order of Precedence.”
7. This designation remains valid unless (a) you change or revoke it, (b) you transfer to another agency, or (c) you leave and
then are reemployed by the Federal Government. If you are covered by (b) or (c), you must fill out a new form if you want
to change the order of payment described under “Order of Precedence.”
NOTE: If this form is not available, any designation, change or cancellation of beneficiary that is witnessed and filed according
to these instructions will be valid.
This form is not to be confused with Standard Form 2808, Designation of Beneficiary, Civil Service Retirement System,
Standard Form 2823, Designation of Beneficiary, Federal Employees’ Group Life Insurance Program, or
Standard Form 3102, Designation of Beneficiary, Federal Employees Retirement System.
Privacy Act Statement
Solicitation of this inf ormation is authorized by the Code of Federal Regulations, Part 178, Subpar t B. The information you
furnish will be used to deter mine the amount, validity, and the person(s) entitled to the unpaid compensation of a deceased
Federal employee. The information may be shared and is subject to verification, via paper, electronic media, or through the
use of computer matching programs to obtain information necessary for determination of entitlement under this program or to
report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they
are investigating a violation or potential violation of the civil or criminal law. Public Law 104-134 (April 26, 1996) requires that
any person doing business with the Federal government furnish a Social Security Number or tax identification number. This
is an amendment to title 31, Section 7701. Failure to furnish the requested information may delay or make it impossible for us
to determine eligibility of payments.
U.S. Office of Personnel Management
Standard Form 1152 (Reverse Part 2)
5 CF
Revised September 2011
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Form 1152 Designation of Beneficiary

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Completed 22 February 2020

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